Hybrid high-power short-duration ablation for atrial fibrillation: a meta-analysis

High-power short-duration (HPSD) radiofrequency ablation, including very-high-power short-duration (vHPSD) and Ablation Index (AI)-guided approaches, has emerged for pulmonary vein isolation (PVI) in atrial fibrillation (AF). A hybrid strategy combining posterior vHPSD with anterior AI-guided ablation has been proposed to leverage the theoretical advantages of each, but its comparative effectiveness remains unclear. This meta-analysis aimed to assess the efficacy, safety, and procedural efficiency of the hybrid ablation strategy compared to vHPSD-only or AI-guided-only approaches for AF. A systematic search of multiple databases was conducted up to June 2026 for studies comparing the hybrid strategy (posterior vHPSD+anterior AI-guided) against uniform control strategies (vHPSD-only or AI-guided-only). Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Eight studies ( n = 2,771 patients) were included. In stratified analyses, the hybrid strategy demonstrated comparable 12-month freedom from atrial arrhythmia to both vHPSD-only (OR 0.97; 95% CI 0.76 − 1.26; P = 0.84) and AI-guided-only (OR 1.06; 95% CI 0.54 − 2.09; P = 0.87) approaches, with similarly low complication rates (vs. vHPSD: OR 1.62, 95% CI 0.79 − 3.29; vs. AI-guided: OR 0.43, 95% CI 0.08 − 2.41). First-pass PVI rates were numerically higher versus vHPSD-only (OR 1.26; 95% CI 0.92 − 1.73; P = 0.15) but not versus AI-guided-only (OR 1.22; 95% CI 0.66 − 2.27; P = 0.53). Ablation duration was longer than vHPSD-only (MD 7.95 min, 95% CI 7.15 − 8.75, P < 0.00001) but shorter than AI-guided-only (MD − 2.00 min, 95% CI − 3.11 to − 0.89, P = 0.0004). Total procedure time was not conclusively longer than vHPSD-only (MD 13.28 min, 95% CI 1.22 − 25.34, P = 0.03, not-robust in sensitivity analysis) but comparable to AI-guided-only (MD 3.18 min, 95% CI − 12.42 to 18.77, P = 0.69). This review was not prospectively registered. Certainty of evidence is limited by the predominance of observational studies and heterogeneity in control group definitions. The hybrid strategy demonstrated comparable 12-month efficacy and safety versus uniform approaches, without superiority in any endpoint. A numerically higher first-pass PVI rate versus vHPSD-only was a hypothesis-generating surrogate finding. Ablation time was intermediate. The hybrid approach represents an anatomically informed alternative, but superiority over uniform strategies remains unproven.